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Donavan Pham MD

Are Residents in Canada Overworked and Underpaid?

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On 9/16/2018 at 6:02 PM, Lactic Folly said:

Clerks are students, not employees (unlike residents who have dual status). The work that they do is basically hands-on training, and is supervised by residents and staff, who also see the patient, check the student's work, and are 100% responsible for any errors or omissions. 

It's just an odd concept since I never really expected pay as a clerk - any stipend was a bonus, as there are other professions where students do unpaid practicums as part of their training. Of course, clerks aren't useless, and often they can spend the most time talking to patients which is very valuable. I was just curious what services wouldn't function properly without clerks (except perhaps when extra retractors are needed in the OR). Are there still many services where clerks do solo call without resident backup?

Ref. House of God Law #11.

CTU comes front and center to mind. This depends on the school, but many medical schools have clerks take first call for their own team's pager overnight and are distributed consults by the SMR overnight. In fact, clerks were essentially JMRs who couldn't sign orders and saw one or two less patients a day. 

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Yeah... in that case SMR still assesses the patient, and JMR is needed to cosign all orders, so there's still quite a bit of supervision. I meant clerk solo in house with resident on home call - which I actually did a few times, but has presumably been phased out by now (along with clerk orders being processed without resident cosign).

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5 minutes ago, Lactic Folly said:

Yeah... in that case SMR still assesses the patient, and JMR is needed to cosign all orders, so there's still quite a bit of supervision. I meant clerk solo in house with resident on home call - which I actually did a few times, but has presumably been phased out by now (along with clerk orders being processed without resident cosign).

After the first week, I never needed orders signed off in CTU. I think atypical compared to other classmates admittedly. My senior residents trusted me to run anything exotic by them, otherwise I was free to note "discussed with dr. X". All the basic day to day labs never needed to be discussed after it was shown I was competent enough in week 1.

Even on my ED rotation, most preceptors told me to order whatever I wanted if I thought it was indicated except again, exotic things like special very low yield assays etc that were expensive without justifying it to them. Any basic imaging like radiograph, CT and US was fair game. As with all emergency room type labs. 

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28 minutes ago, Edict said:

CTU comes front and center to mind. This depends on the school, but many medical schools have clerks take first call for their own team's pager overnight and are distributed consults by the SMR overnight. In fact, clerks were essentially JMRs who couldn't sign orders and saw one or two less patients a day. 

My current experience.

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Ok, but writing "discussed with dr. X" still means that someone else is noted as responsible on the chart, and the unit clerks treat it as being from the resident/attending. I meant orders being processed when signed with the student's name alone, without the "discussed with" notation.

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3 minutes ago, Lactic Folly said:

Ok, but writing "discussed with dr. X" still means that someone else is noted as responsible on the chart, and the unit clerks treat it as being from the resident/attending. I meant orders being processed under the clerk's name alone, without the "discussed with" notation.

Okay, but going back to your question about services that wouldn't function without clerks, CTU definitely comes to mind. At most centers, theres 1 staff, 1 SMR, 3 JMRs (usually 1-2 off service) and 2-3 clerks for 30 patients or so. On a daily basis, 1 person is post-call, often someone is on a half-day, SMR usually doesn't assign themselves patients which often means you have 5-8 patients per person, now take away the clerks and you may have 15-30 patients per JMR. Sure, staff and SMR could pitch in, but the service would be absolutely dysfunctional without clerks. 

 

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CTU by its very name and design is structured around medical education. If I recall correctly, during my internal medicine rotation, there were a few staff in the same hospital who did not have any trainees but carried a similar patient load; I am sure not having to teach, speed rounding, and dictating short focused notes helped greatly with efficiency. The internists here can comment better on this.

We're a bit off from the topic of resident pay, but to the question of clerk pay, in my mind it would be the same as paying nursing students, tech students, etc. for their contributions to patient care during their 3rd and 4th year practicums. I'm not sure that they receive any stipend to offset their tuition, but anyone in the know can correct me.

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47 minutes ago, Lactic Folly said:

CTU by its very name and design is structured around medical education. I'd be curious how many patients a community hospital internist could take on by themselves, with no trainees, speed rounding, and short focused notes?

My experience is it is usually a floor, so about 30ish patients with sometimes a PA to help with paperwork and arranging services. Less of course if it is ICU etc. 

It is actually interesting seeing how efficient staff really are when they are cut loose from all the academic ties. You just don't get to see it that often as a clerk or resident. That goes for almost any branch of medicine really - and it is why in large part community docs earn more than academic ones (which doesn't make sense - in a fee for service system should a staff with all these people helping them at a big hospital do so much better? and yet no, not at all.) They are fast and efficient because they have to be, and everything is streamlined as a result. They aren't wasting time figuring out what to do most of the time - they know so much more than trainees to. There is no teaching, no case discussion, no distractions etc, etc. Speaking from my specialty again it is why is part community rads do usually twice the volume of academic radiologists - even though academic rads have fellows and senior residents often to support them. It is all about getting through the work so you can go home etc. 

That doesn't change the fact that in an academic centre the way it is set up there are some services where clerks have a mandated role, and they are important in that role. 

 

Edited by rmorelan

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29 minutes ago, rmorelan said:

My experience is it is usually a floor, so about 30ish patients with sometimes a PA to help with paperwork and arranging services. Less of course if it is ICU etc. 

It is actually interesting seeing how efficient staff really are when they are cut loose from all the academic ties. You just don't get to see it that often as a clerk or resident. That goes for almost any branch of medicine really - and it is why in large part community docs earn more than academic ones (which doesn't make sense - in a fee for service system should a staff with all these people helping them at a big hospital doing so much better? and yet no, not at all.) They are fast and efficient because they have to be, and everything is streamlined as a result. They aren't wasting time figuring out what to do most of the time - they know so much more than trainees to. There is no teaching, no case discussion, no distractions etc, etc. Speaking from my specialty again it is why is part community rads do usually twice the volume of academic radiologists - even though academic rads have fellows and senior residents often to support them. It is all about getting through the work so you can go home etc. 

That doesn't change the fact that in an academic centre the way it is set up there are some services where clerks have a mandated role, and they are important in that role. 

 

Same for surgueies. It takes me about 25-50% of the time to do a case as a staff in the community vs the academic guys. That's because I operate all the time. I don't have trainees doing 75% or more of the case. 

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1 hour ago, JohnGrisham said:

After the first week, I never needed orders signed off in CTU. I think atypical compared to other classmates admittedly. My senior residents trusted me to run anything exotic by them, otherwise I was free to note "discussed with dr. X". All the basic day to day labs never needed to be discussed after it was shown I was competent enough in week 1.

Even on my ED rotation, most preceptors told me to order whatever I wanted if I thought it was indicated except again, exotic things like special very low yield assays etc that were expensive without justifying it to them. Any basic imaging like radiograph, CT and US was fair game. As with all emergency room type labs. 

I'm not sure any of this shows the essentialness of clerks let alone that they're doing work that should be compensated like a job. In community centres, nurses will often enter "routine" bloodwork themselves without any MD input (imagine!) because they're used to things working like that. Assessments and rounding takes no time at all; the only stuff that I never feel quick at are the note-writing and, of course, patient/family counselling. 

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2 hours ago, Edict said:

Okay, but going back to your question about services that wouldn't function without clerks, CTU definitely comes to mind. At most centers, theres 1 staff, 1 SMR, 3 JMRs (usually 1-2 off service) and 2-3 clerks for 30 patients or so. On a daily basis, 1 person is post-call, often someone is on a half-day, SMR usually doesn't assign themselves patients which often means you have 5-8 patients per person, now take away the clerks and you may have 15-30 patients per JMR. Sure, staff and SMR could pitch in, but the service would be absolutely dysfunctional without clerks. 

 

I have been on several teams where we had no medical students (at all), both during the day or on call at night. They are by no means essential to running my CTU team. If I am the on call SMR and I have no medical students, then I cover the ward pages, as well as admit to my own team with no issues (I'll likely be up all night anyways)

If I have no medical students during the day then the JMR's might take 2 extra patients each, and/or I will easily pick up the slack and can see 5+ patients myself.

No offense but CTU can and has run without medical students (at least I can only comment about UofT, but I'm sure this is similar at other sites). Can clerks save time for the team? of course! but it usually balances out for the most part.

Even with medical students (even excellent ones, that function like JMR's) I always know what is going on behind the scenes and implement investigation/management plans, if the medical student doesn't know or missed it etc..., they are their to learn ultimately. I even do this with my JMR's but to a less extent depending on the complexity of the patient, whether they are a medicine resident vs off service etc... and try to give them autonomy without sacrificing patient care. All the SMR's I know do this and we make it seem like we are giving all the power to our JMRs and medical students. Any SMR that says they don't are lieing or are not doing their job

Note: I really like having medical students, especially ones that like internal medicine and/or want to do internal. I like being able to teach them and have them learn and eventually grow as clinicians. That doesn't mean they are essential to my team by any means.

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2 hours ago, Edict said:

Okay, but going back to your question about services that wouldn't function without clerks, CTU definitely comes to mind. At most centers, theres 1 staff, 1 SMR, 3 JMRs (usually 1-2 off service) and 2-3 clerks for 30 patients or so. On a daily basis, 1 person is post-call, often someone is on a half-day, SMR usually doesn't assign themselves patients which often means you have 5-8 patients per person, now take away the clerks and you may have 15-30 patients per JMR. Sure, staff and SMR could pitch in, but the service would be absolutely dysfunctional without clerks. 

 

I happen to know a few community general internists. Once you are into a few years of practice, even with a 30 patient GIM list, you could definitely function faster without clerks or junior residents.

In fact, in community GTA training sites, the GIM staff would often carry the pager themselves, triage the consults, and tell the residents to go home relatively early (before 11 pm)  for a 26 hour call. You are just more efficient as a staff, as your notes don't have to be that extensive, and just to the point. The GIM rounding could be relatively quick, once you get to know the patients relatively well.  If you happen to have a PA or junior resident around to do your paperwork or contacting consultants & family, your day will be less heavy.

For compensation, all the academic staff physicians make 40% less than community staff physicians (for GIM, you are thinking about from 500 k to 300 K--source heard from a GIM academic staff). The reason that they are paid less, is not because of fee-for-service of less volume in academic centers, because all the staff physicians share the money pool, so everyone gets relatively paid the same. At the end of day,  someone has to be the program director (which implies less clinical time), research scientist (publishing crazy for the faculty of medicine and advance medicine), clinician educator (QI projects, design curriculum for medical students, etc). Inherently, clinical work pays much better than research > medical education, hence why everyone shares the money in the first place.

You also have to factor in the time for medical education meetings, evaluation meetings, preparing for rounds & presentations, etc.. 

Bottom line is if you are money oriented, academic hospitals are perhaps not meant for you, you will be expected to get a pay cut compare to your community colleagues. 

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1 hour ago, A-Stark said:

I'm not sure any of this shows the essentialness of clerks let alone that they're doing work that should be compensated like a job. In community centres, nurses will often enter "routine" bloodwork themselves without any MD input (imagine!) because they're used to things working like that. Assessments and rounding takes no time at all; the only stuff that I never feel quick at are the note-writing and, of course, patient/family counselling. 

Oh, I agree clerks shouldn't be paid. Just wanted to provide anecdote that clerks do sometimes function fairly independently for day to day things etc. 

Yes resident and attending can do things 10x faster but having the MSI making calls or spending extra time with family, things that come with managing their 4-5 patients, does free up some time so the JMR or SMR doesn't have to. Yes there is teaching as well, so it evens out but sometimes...not always, there can be a net + in time out of the med student than time put in.

The vast majority of the time though, med students are a time sink.

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Out patient office based family practice is one of the likely exceptions to the med student time/money sink. A well functioning ms4 can manage the average patient on their own with minimal oversight and can definitely be a net positive and more so.

Scenario: geri patients. Get the med student to spend 30mins with them to be thorough, dealing with social aspects and see 10 patients. That saves you time as an attending to see quicker patients and allows the older patients to feel heard and not be rushed etc. Win win win. 

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The question of whether a clerk slows down a resident or staff is irrelevant to the question of whether clerks should be paid or not. At an academic centre, teaching is a part of the game and if that bothers staff then said staff should not be entitled to be at the academic centre. But in regards to pay, Undergrads get 5K for four months of summer research, and for sure they slow down the grad student or supervisor too. Engineering students doing co-op get paid. A new hire at any government or industry job also needs teaching and is not super productive at first, yet they still receive a salary. Same for any high school student learning to use the cash register. Clerks are working 60-90 hrs per week, and while yes they need teaching and are students, (a) said teaching is part of the staffs job description, and (b) the clerk is still contributing to patient care, even if it’s just wheeling in a stretcher post-OR, writing a note or dabbing a wound, let alone fielding CTU call over night - this is not unlike the engineering co-op model where they are a learner, but still getting a bit of financial support for their efforts. We pay people minimum wage for far less in other disciplines, so I think pitching a bit of money towards the clerk for the year, even just a small amount, would be justified. 

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14 minutes ago, ZBL said:

The question of whether a clerk slows down a resident or staff is irrelevant to the question of whether clerks should be paid or not. At an academic centre, teaching is a part of the game and if that bothers staff then said staff should not be entitled to be at the academic centre. But in regards to pay, Undergrads get 5K for four months of summer research, and for sure they slow down the grad student or supervisor too. Engineering students doing co-op get paid. A new hire at any government or industry job also needs teaching and is not super productive at first, yet they still receive a salary. Same for any high school student learning to use the cash register. Clerks are working 60-90 hrs per week, and while yes they need teaching and are students, (a) said teaching is part of the staffs job description, and (b) the clerk is still contributing to patient care, even if it’s just wheeling in a stretcher post-OR, writing a note or dabbing a wound, let alone fielding CTU call over night - this is not unlike the engineering co-op model where they are a learner, but still getting a bit of financial support for their efforts. We pay people minimum wage for far less in other disciplines, so I think pitching a bit of money towards the clerk for the year, even just a small amount, would be justified. 

The difference is in the coop fields you tend to have far clearer goals and outcomes. I did far more tangible and measurable work in coop terms than as a clinical clerk. And I was paid appropriately, far more than minimum wage.  You're a learner too, but you still have defined work that you are expected to complete and perform. 

I dont think any of the healthcare fields have paid clerkships/rotations. Med, dent, nursing, physio, OT etc. Nor should they as some feel. Yes you're contributing but the main goal is to be learning as an apprentice. 

 

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Engineering co-ops are mostly private industry competing to get the best students. They hope they can idendify and recruit good permanent employees via this method. Private industry is willing to spend money to do this. They hope this will let them make more money in the future.

The governments in Canada are cheap. They have no profit motive. They know you will still be working in the public system for whatever they decide the fee schedule is when you are done. They don't need to pay you and as a result, they don't. Same goes for teachers.

It sucks, but unfortunately that is the reality.

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9 hours ago, JohnGrisham said:

Out patient office based family practice is one of the likely exceptions to the med student time/money sink. A well functioning ms4 can manage the average patient on their own with minimal oversight and can definitely be a net positive and more so.

Scenario: geri patients. Get the med student to spend 30mins with them to be thorough, dealing with social aspects and see 10 patients. That saves you time as an attending to see quicker patients and allows the older patients to feel heard and not be rushed etc. Win win win. 

True I noticed that our staff do like to give the geriatric and psychiatric patients to MS4 or junior residents lol

At the same time, you do have to review with medical students and see the patient with them, also teach around cases. In academic family health teams, staff will block time slots during their day schedule to review with residents & medical students, etc. 

I think that if you want to be an academic staff physician, you have to love teaching, and be willing to take 30- 40% paycheck cut. 

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22 hours ago, ACHQ said:

I have been on several teams where we had no medical students (at all), both during the day or on call at night. They are by no means essential to running my CTU team. If I am the on call SMR and I have no medical students, then I cover the ward pages, as well as admit to my own team with no issues (I'll likely be up all night anyways)

If I have no medical students during the day then the JMR's might take 2 extra patients each, and/or I will easily pick up the slack and can see 5+ patients myself.

No offense but CTU can and has run without medical students (at least I can only comment about UofT, but I'm sure this is similar at other sites). Can clerks save time for the team? of course! but it usually balances out for the most part.

Even with medical students (even excellent ones, that function like JMR's) I always know what is going on behind the scenes and implement investigation/management plans, if the medical student doesn't know or missed it etc..., they are their to learn ultimately. I even do this with my JMR's but to a less extent depending on the complexity of the patient, whether they are a medicine resident vs off service etc... and try to give them autonomy without sacrificing patient care. All the SMR's I know do this and we make it seem like we are giving all the power to our JMRs and medical students. Any SMR that says they don't are lieing or are not doing their job

Note: I really like having medical students, especially ones that like internal medicine and/or want to do internal. I like being able to teach them and have them learn and eventually grow as clinicians. That doesn't mean they are essential to my team by any means.

I won't deny that what you said is true, but every med student that read this just went to the washroom to cry :unsure: Now the poor med students can sleep knowing that not only do they work 60-80 hour weeks and pay tuition to do so, but they also slow everyone down too lol

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9 minutes ago, Edict said:

I won't deny that what you said is true, but every med student that read this just went to the washroom to cry :unsure: Now the poor med students can sleep knowing that not only do they work 60-80 hour weeks and pay tuition to do so, but they also slow everyone down too lol

Aha I won't put it this way. I think that clerkship is a steep learning curve, where you learn what you like in medicine, what you don't like, and find models within your staff physicians. I find that in high acuity services (general surgery), having clerks around definitely help the patient flow .

Clerkship is all about learning and finding what kind of physician you want to be. Also, I find clerkship the most challenging part of my life, because of the power differential---> nobody has respect for you, everyone yells at you or shoves you around ( in certain unfriendly services); while you have to remain optimistic and try to put a big grin on your face, and carry on with your learning and trying desperately to impress your residents who are perhaps overworked, or try to impress your staff physicians for LORs (who doesn't interact with you that much tbh).

Once you passed through clerkship---> life seems to be easier in residency where you have more autonomy and more respect from the other health professionals. 

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2 minutes ago, LittleDaisy said:

Aha I won't put it this way. I think that clerkship is a steep learning curve, where you learn what you like in medicine, what you don't like, and find models within your staff physicians. I find that in high acuity services (general surgery), having clerks around definitely help the patient flow .

Clerkship is all about learning and finding what kind of physician you want to be. Also, I find clerkship the most challenging part of my life, because of the power differential---> nobody has respect for you, everyone yells at you or shoves you around ( in certain unfriendly services); while you have to remain optimistic and try to put a big grin on your face, and carry on with your learning and trying desperately to impress your residents who are perhaps overworked, or try to impress your staff physicians for LORs (who doesn't interact with you that much tbh).

Once you passed through clerkship---> life seems to be easier in residency where you have more autonomy and more respect from the other health professionals. 

The idea that a clerkship has to be somehow has a focus on productivity as well I think is dangerous. You are there to learn medicine. Ideally you aren't extremely slow but putting them on a productivity mindset specifically is wrong. 

Clerks usually slow things down - that is ok. It's a teaching hospital. That is the way things are and the way things have been since time immemorial. You need to focus on doing it right more than doing it fast. You need to start with small things and move to bigger things.  

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28 minutes ago, Edict said:

I won't deny that what you said is true, but every med student that read this just went to the washroom to cry :unsure: Now the poor med students can sleep knowing that not only do they work 60-80 hour weeks and pay tuition to do so, but they also slow everyone down too lol

Hahahahahah sorry I didn’t mean to be so harsh, but it is the reality of the situation. Some of the best medical students will be an asset to a team (an asset as much as a JMR can be). My point was that CTU won’t crumble in their absences.

tbh I could care less if med students slow me down, but their job during their IM rotation is NOT to help make me more efficient (which they cannot do anyways), it’s to learn Internal medicine. I WANT my clerks learn something that they can carry with them forward regardless of what they eventually go into, even if it means we have to spend a little bit more time for it. 

“CTU” is a constructed system to teach medical students and residents internal medicine. As people mentioned if we just wanted to provide patient care and peace out we could (like how weekend rounding works, although we’re on call and there the whole day ahah)

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43 minutes ago, Edict said:

I won't deny that what you said is true, but every med student that read this just went to the washroom to cry :unsure: Now the poor med students can sleep knowing that not only do they work 60-80 hour weeks and pay tuition to do so, but they also slow everyone down too lol

Ha actually if you think of it like this and focus on the learning (which was the original intention, being a student), paying tuition seems much more justified than if you focus on the work you're contributing. It becomes easier to digest although you're not content about it

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5 hours ago, Eudaimonia said:

Ha actually if you think of it like this and focus on the learning (which was the original intention, being a student), paying tuition seems much more justified than if you focus on the work you're contributing. It becomes easier to digest although you're not content about it

The amount of learning I had on some m3 rotations was very minimal on the actual ward. Learned more with case files and aafp.

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18 hours ago, JohnGrisham said:

The amount of learning I had on some m3 rotations was very minimal on the actual ward. Learned more with case files and aafp.

about medicine or about overall functioning of ward work etc etc. I mean it was pretty variable for me as well  - some CTU staff were amazing and some less so. A lot clerkship seemed more about how to fit into the hospital system and look/feel like you belonged there over strictly the medicine part of things. 

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